INFORMED CONSENT STATEMENT

Study # ( )

INDIANA UNIVERSITY – BLOOMINGTON

INFORMED CONSENT STATEMENT
[List title of project here] (item 2)

You are invited to participate in a research study. (item 3) The purpose of this study is
_____________________________________________________________________________
____. (item 3-a)

INFORMATION

Describe all procedures, preferably in chronological order, which will be employed in the study.
Point out any that are considered experimental and explain technical and medical terminology
(item 3-b).

State the amount of time required of the subject per session and for the total duration of the study
(item 3-c).

If applicable to your study, describe:

Alternative procedures or courses of treatment [when experimental procedures are being used]
(item 4).

The number of subjects that will be participating in the research (item 12).

Information concerning taping or filming (item 13).

A disclaimer for the use of deception (item 14).

RISKS

List the foreseeable risks or discomforts, if any, of each of the procedures to be used in the study,
and any measures which will be used to minimize the risks (items 3-d & e).

EMERGENCY MEDICAL TREATMENT (item 15, if applicable add here)

In the unlikely event of physical injury resulting from your participation in this research,
emergency medical treatment will be provided at no cost to you. Be certain that you immediately
notify the researcher if you are injured. If you require additional medical treatment you will be
responsible for the cost. No other compensation will be provided if you are injured in this
research.

BENEFITS

List the benefits you anticipate will be achieved from this research, either to the subjects, others,
or the body of knowledge (item 3-f). (There may be no direct benefits to the subjects, but benefits
to the body of knowledge in general.)

CONFIDENTIALITY (item 5)

Describe the extent, if any, to which confidentiality of records identifying the subject will be
maintained. OR, explain when and how confidentiality will be broken.

COMPENSATION (item 6, if applicable add here)

For participating in this study you will receive _____________________. Other ways to earn the
same amount of credit are _______________________. If you withdraw from the study prior to
its completion, you will receive _____________________________.
______________
subject’s
initials

(Number pages, e.g. 1 of 2)

3/01;www;msw -13-
CONTACT (items 7 & 8)

If you have questions at any time about the study or the procedures, (or you experience adverse
effects as a result of participating in this study,*) you may contact the researcher, [name] , at
[address] , [phone number] , and [e-mail] .

If you feel you have not been treated according to the descriptions in this form, or your rights as a
participant in research have been violated during the course of this project, you may contact the
office for the Indiana University Bloomington Human Subjects Committee, Carmichael Center
L03, 530 E. Kirkwood Ave., Bloomington, IN 47408, 812/855-3067, by e-mail at
iub_hsc@indiana.edu.

PARTICIPATION (items 9 & 11)

Your participation in this study is voluntary; you may refuse to participate without penalty. If you
decide to participate, you may withdraw from the study at any time without penalty and without
loss of benefits to which you are otherwise entitled. If you withdraw from the study before data
collection is completed your data will be returned to you or destroyed.

CONSENT (item 10)

I have read this form and received a copy of it. I have had all my questions answered to my
satisfaction. I agree to take part in this study.

Subject's signature_______________________________________ Date

_________________

I agree to allow my child, ________________________, to take part in this study.

Parent's signature_______________________________________ Date

_________________

Witness signature__________________________________ Date _________________

(required if form is read to subject)

Consent form date: (date you construct or revise the form)

(Number pages, e.g., 2 of 2)